Results Update

Three healthcare organizations partnered to prevent HAPIs using Robust Process Improvement. The teams used RPI to identify 23 root causes in their daily work, implemented countermeasures to address them and sustained 62% improvements in HAPI rates, with a validated savings of $15.3MM.

Prevention of HAPU/I

Hospital Acquired Pressure Ulcers/Injuries (HAPU/I) result in significant patient harm, including pain, expensive treatments, increased length of institutional stay and, in some patients, premature mortality. It is estimated each year more than 2.5 million patients in U.S. acute-care facilities suffer from pressure ulcer/injuries and 60,000 die from their complications. The cost of treating a single full-thickness pressure ulcer/injury can be as high as $70,000, and total costs for treatment of pressure ulcer/injury in the United States is estimated at $11 billion annually.

The Agency for Healthcare Research and Quality found that despite a 13 percent decrease in all hospital-acquired conditions from 2014-2017, HAPU/I rates have risen by six percent.

There are many barriers to consistent, successful implementation of preventative measures for HAPU/I. The project utilized Robust Process Improvement® (RPI®) methodology with three participating hospitals. RPI is a fact-based, systematic, and data-driven problem-solving methodology which incorporates tools and concepts from Lean Six Sigma and Change Management.

Project Team

This methodology facilitated the identification of the root causes and barriers to preventing HAPU/I (s) in at-risk patients. The participating hospitals identified and developed solutions to target their organization’s specific root causes. Starting from evidence-based practices and utilizing robust process improvement techniques detailed investigation, change management, and analysis were completed. The hospital teams identified five significant contributing factors resulting in 23 root causes validated, and solutions targeted to those root causes were implemented. Each solution was piloted, validated and sustained by the teams.

Project team

The Johns Hopkins Hospital
Kaiser Permanente South Sacramento Hospital
Memorial Hermann Southeast Hospital in Houston

For more information on the project, please see the blog and press release.